ANESTHETIC PROCEDURE RELEASE FORM

*If you are unsure of this form and would like to discuss it with a staff member when you come in for surgery, please click the link below to bypass the release form.

https://form.jotform.com/230616437195054
ANESTHETIC PROCEDURE RELEASE FORM
Name*

First NameLast Name
Pets Name*
Date of Procedure*
BEST NUMBER TO REACH IN CASE OF EMERGENCY*
*If we cannot reach you while your pet is under anesthesia and we do not hear back from you or the appointed caretaker within 15 minutes, a professional medical decision will be made by the surgery doctor. You as the owner will be finiacially responsible for any additional charges.
CURRENT MEDICATIONS AND WHEN THEY WERE LAST GIVEN:*
IF NO CURRENT MEDICATIONS, ENTER "N/A"
FEMALES ONLY
WHEN WAS THE LAST HEAT CYCLE
WHEN WAS THE LAST PREGNANCY
Hover above each field to read additional information
COST FOR CBC/CHEM LABWORK IS $138*

Yes - Please run labsNo - I will pass on labs at this time
COST FOR IV CATHETERIZATION AND IV FLUIDS ARE $103*

Yes - I would like my pet to receive IV fluidsNo - I will pass on IV fluids at this time
HISTOPATHOLOGY $135 (MASS REMOVAL/BIOPSY ONLY)

Yes - I would like to send out my pet's mass for testingNo - I will pass on testing at this time
VACCINES/ANNUAL TESTING

These can be completed early if they coming up due.
CANINES ONLY

Hover over each field to read additional information
RABIES - Rabies is required per TVC policy at 16 weeks of age - If proof of current rabies is not provided, vaccine one will be administered at owners expense.

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVC
DHLPP

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
LEPTOSPIROSIS

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
LYME

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
BORDETELLA (if they go to a kennel or groomer)

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
4DX TEST ***Tests for Heartworm disease, as well as 3 tick born diseases - Lyme, Anaplas, and Ehrlichia.

Complete if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time - I will not be purchasing heartworm preventative this yearDecline at this time - I will request a waiver form in order to purchase heartworm preventative without diagnostic test
FECAL EXAM

Complete if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
SAVE THIS LIFE MICROCHIP

I request to have a microchip implantedDecline/not interested at this timeMy pet already has a microchip
FELINES ONLY

Hover above each field to read additional information
RABIES - Rabies is required per TVC policy at 16 weeks of age - If proof of current rabies is not provided, vaccine one will be administered at owners expense.

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVC
FVRCP

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
FELINE LEUKEMIA (strongly recommended for outside cats)

Complete vaccine if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
FELINE LEUKEMIA TEST

Complete if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
FECAL EXAM

Complete if due or coming dueMy pet is current/I will provide certificate if not administered at TVCDecline at this time
SAVE THIS LIFE MICROCHIP

I request to have a microchip implantedDecline/not interested at this timeMy pet already has a microchip
DENTAL PROCEDURES ONLY
DO YOU AUTHORIZE EXTRACTIONS IF THEY ARE NECESSARY?

YesNo
If you would like to be contacted prior to extractions please list the best number to reach you at.
Please enter a valid phone number.
Extractions are only done if they are deemed necessary **If you answer no and we cannot reach you in a timely fashion, your pet will be woke up from anesthesia and rescheduled for extractions. A new estimate can be provided for this 2nd procedure at your request. **
SPECIAL INSTRUCTIONS / ADDITIONAL REQUESTS
WOULD YOU LIKE A BUSTER COLLAR? ($12)*

YesNo
DO NOT RESUSCITATE (DNR) ORDER - (please hover over the field for additional information - click the field if filling out the form via cellular phone)*

Approve DNR - I direct Thompson Veterinary Clinic to withhold resuscitative measures from my pet in the event of cardiopulmonary arrest.Decline DNR - I direct Thompson Veterinary Clinic to perform resuscitative measures in the event of cardiopulmonary arrest.
If you answered yes to the above field, please read the below statement and sign accordingly.

I, the undersigned, being of sound mind and legal age, willfully and voluntarily make this declaration to state my desires and direct that resuscitation be withheld or withdrawn in the event of my pet listed above has cardiac or respiratory arrest. It is my intention that this order be honored by my family, my veterinarians, and all others who may partake in my pets health care.
TYPE SIGNATURE
DATE SIGNED
By typing your name below, you are also indicating you have been informed of the risks involved with anesthesia, and you have had an opportunity to discuss these risks with a veterinarian. Your signature further indicates you accept these risks and give the Thompson Vet Clinic permission to anesthetize your pet.Thompson Vet Clinic will utilize all reasonable precautions against injury, escape, or death of your pet.
TYPE SIGNATURE*
DATE SIGNED*
Should be Empty:

ANESTHETIC PROCEDURE RELEASE FORM

FEMALES ONLY

VACCINES/ANNUAL TESTING

CANINES ONLY

FELINES ONLY

DENTAL PROCEDURES ONLY